Lecture 10 - Palliative Care

Question 1

8 Domains of Quality Palliative care

Answer 1

1. structure and process of care
2. physical aspects of care
3. psychological and psychiatric aspects of care
4. social aspects of care
5. spiritual, religious and existential aspects of care
6. cultural aspects of care
7. care of the pt at the end of life
8. ethical and legal aspects of care

Question 2

For hospice, life expectance has to be under….

Answer 2

6 month

Question 3

Types of pain

Answer 3

Nociceptive
Neuropathic
Existential
Mixed

Question 4

How to asses pain

Answer 4

FACES = pictures
Numerical Rating Scale
PQRST

Question 5

Morphine Dose Adjustments

Answer 5

Renal: avoid in severe impairment
Hepatic: favorable w/ monitoring, inc dosing interval if severe impairment

Question 6

Oxycodone Dose Adjustments

Answer 6

Renal: favorable with monitoring
Hepatic: cation n monitor, reduce dose 50% or inc dosing interval if severe

Question 7

Hydromorphone Dose Adjustments

Answer 7

Renal: favorable with monitoring
Hepatic: caution n monitor, reduce dose 50% or inc dosing interval if severe

Question 8

Fentanyl Dose Adjustments

Answer 8

Renal: preferred opioid in impairment
Hepatic: avoid in severe impairment, reduce doe 50% if mild-moderate

Question 9

Methadone Dose Adjustments

Answer 9

Renal: preferred opioid in impairment
Hepatic: Avoid liver failure or severe impairment

Question 10

Adverse effects opioids

Answer 10

constipation
Sedation
Respiratory depression
N/V
Pruritus
Hallucinations
Confusion/delirium
Myoclonus

Question 11

Morphine dosing

Answer 11

10mg IV = 30mg Oral

Question 12

Hydrocone to morphine

Answer 12

30mg Oral = 30mg Morphine Oral

Question 13

Hydromorphone dosing equiv

Answer 13

1.5mg IV = 7.5mg Oral (= 30mg morphine oral)

Question 14

Oxycodone to morphine equiv

Answer 14

20mg Oral = 30mg Oral morphine

Question 15

Oxymorphone Dosing equiv

Answer 15

1mg IV = 10mg Oral (= 30mg Morphine oral)

Question 16

Daily dosage 60-134mg Morphine Fentanyl equiv

Answer 16

25mcg/h patch

Question 17

Daily dosage 135-224mg Morphine Fentanyl equiv

Answer 17

50mcg/h patch

Question 18

Daily dosage 225-314mg Morphine Fentanyl equiv

Answer 18

75mcg/h patch

Question 19

Daily dosage 315-404mg Morphine Fentanyl equiv

Answer 19

100mcg/h

Question 20

Going from Fentanyl patch to morphine

Answer 20

1. remove patch
2. for 1-12hrs after, use PRN opioid only
3. at 12hrs, start new scheduled opioid at 50% of dose
4. at 24hrs, inc new scheduled opioid at 100% of dose

Question 21

If taking methadone w/ enzyme inducer then….

Answer 21

might need to inc methadone, use rescue opioid

Question 22

If taking methadone w/ enzyme inhibitor then….

Answer 22

reduce calc dose of methadone by 25% or more, encourage use of rescue opioid

Question 23

Appropriate Methadone Candidates

Answer 23

True morphine allergy
Sig renal impairment
Neuropathic pain
Opioid-induced adv effects
Pain refractory to other opioids or uncontrolled pain
Cost is an issue
LA opioid preferred
any opioid req patient

Question 24

Supplemental opioids

Answer 24

want to use same as Long acting
should be about 10-15% of Total daily dose, can be used Q1-6h PRN

Question 25

Corticosteroids indicated for…

Answer 25

moderate to severe somatic and visceral pain as single agent or combo with agents

used in bone pain

Question 26

Bowel Regimen

Answer 26

should start stimulant laxative w/ opioids

if no BM in 2+ days, titrate up stim laxative and can add osmotic

inc fluid intake, exercise/mobility and fiber in diet

Question 27

drugs for Dyspnea

Answer 27

usually opioids and that conc oral morphine

give really small dose to patients

Question 28

Pharm therapy for anxiety

Answer 28

1st line = SSRI/SNRI
2nd = Benzo
3rd = Adjunctives

Question 29

Risk factors for depression in serious illness

Answer 29

Age = younger pts
Prior history of depression
Uncontrolled symptoms
Type of illness

Question 30

Gold standard for depression in serious illness

Answer 30

PHQ-9
> 10 = indicates likely major depression in general population

in pts w/ serious illness, lower threshold (> 6) should be consideration of txm

Question 31

symptoms clusters

Answer 31

when 3 or more concurrent symptoms are related to each other